This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.

Friday, February 23, 2007

If man were made to fly . . .

Story in the Boston Globe today. I reprint it in its entirety. [Oops. No I don't. Thanks to Dan Kennedy for pointing out the copyright infringement. So, I have modified this posting to include excerpts. Many apologies to the Globe.]

Blog tests hospital leaders' patienceBeth-Israel CEO jabs competitors

By Liz Kowalczyk, Globe Staff February 23, 2007

There are some things that Boston hospital executives generally believe are best kept quiet. Gripes about competitors are one. The rates of hospital-acquired infections among patients are another, at least at this point.

Then came Paul Levy's blog.

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He challenged other hospitals to publicize their infection rates.... The Globe asked several other Boston teaching hospitals if they would release their monthly central line infection rates, which they have collected internally for years. They all said no, at least for now, but added they expect to in the near future.

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In his blog, Levy also has needled Partners HealthCare, the parent organization of Mass. General and Brigham and Women's, about their formidable market share of patients, saying they get paid more from insurers because of their size.

31 comments:

I only became aware of your work on this blog after reading the Globe this morning. I love it. I applaud your efforts toward transparency, especially on important issues such as line infection rates.

The old arguement, that the public is not smart enough to interpret the information (in this case, different infection rate measuring methodologies) is just no longer valid. I annoys me to no end. Head in sand. Wouldn't it be great if all Boston hospitals took a national leadership position in sharing elements of their performance?

Please keep up the good work. Continue to push the envelop on transparency. Especially on the complexity of running a hospital. It is good to see evidence a real leader in Boston healthcare, that realizes this is the 21st century.

Even in Boston, this is not the old paternalistic medicine model where consumers rely on brand, and cannot interpret inormation and make their own choices.

Let’s assume that patients will seek out and draw conclusions from information that’s publicly available regarding a hospitals performance.

Infection rate measures are already available on-line to patients whether an institution likes the methodology or not. So a hospital that protects it’s own outcome data has little to gain. But the information that’s available is not always current. So let’s think this through a bit. If a hospital were reluctant to publish it's own current outcome measures, wouldn’t that imply that their current outcomes, using the same methodology, have perhaps diminished in comparison?

If I were a patient, I would have to draw the conclusion that any hospital that does not publicly make available current infection rate data would be attempting to avoid self-incrimination.

I think your thoughts and challenges are great. Coming from a frequent patient's point of view I'd love to be able to see this type of information. I'm going in for surgery soon at another Boston hospital and I'd love to know a bit more about where I'm going.

This blog is a good example of how a corporate entity can use a blog to genreate publicity and address the issue of transparency. How do you feel that your blogging adventures have changed things at your job? (If at all).

Hold it folks! MA hospitals, not just BIDMC, are publicly reporting 20+ measures at present, and 30 by year end. Check it out on hospitalcompare.hhs.gov. In addition, MA hospitals are all voluntarily participating in Patients First, measuring NQF-endorsed nursing-sensitive measures, which will be posted this summer. Further, MA hospitals agreed to voluntarily measure and report on two key infection measures (ventilator associated pneumonia and central line associated blood stream infections) but plans are on hold until the standard-setting organization, NQF, clarifies some reporting issues. And the state reports another dozen at mass.gov/healthcareqc. Short story: hospitals are willing to be transparent, WHEN there is a common language and level playing field.

I've been reading this for a while, and I think you're doing the right thing. While I don't have a choice of what hospital I go to (as I assume most people don't--it's dictated by what hospital my Dr. is affiliated with), I still think this is good information to have.

And I have to repeat: hooey to those who don't think I can understand what I'm told.

It's all well and good to spout "we're a partner in your health care" that the doctors, drug companies, insurance companies, and hospitals do. That "partner" goes both ways. I'm doing my part. Where are they?

Maybe ileana, but when it comes to being a customer, I almost always go with businesses that have an internet presence, whether it be an accountant, lawyer, or any other professional. Personally I think it speaks volumes for their ability to change with the times.

If a physician purports to not use the internet then I steer clear because there are now medical profession publications which are distributed *only* on the internet and that means the MD is falling behind on knowlege, which scares me.

If a CEO, who has a vast responsibility for communication, does not know what one of the most popular communication tools on the internet is, well that says a lot.

Keep holding their feet to the fire. High time that someone (thank goodness it is you) opened up and put the data out there good or bad. It makes everyone accountable. Plus it allows your hard working employees to celebrate a job well done.

Oh, don't get me wrong. I completely agree with that. It does speak a lot about their abilities to adapt.

Let's admit it though, Paul is cool, but he is the exception rather than the rule. I am sure that there are hospital CEOs and COOs out there that do an amazing job and still don't know what a blog is...

What do we really want these guys to do? Be transparent and publish their data. I can hardly imagine that embarassing them like that is going to make things easier.

Paul, as a young person working in the Boston health care arena, I'd love to hear more from you about being a non-MD while holding your current title and position. How did you get there? And what advice do you have for other young non-MDs who would like to make a career in academic medicine?

Congratulations on the attention your blog has attained. Also it takes a lot of integrity to post hospital issues about complications on a blog. I am sure you are taking a lot of heat about that one. Carry on. Feel free to peruse my blog at www.healthtrain.blogspot.com and also www.trusted.md a source that syndicates many blogs. You are welcome to join trusted.md I am one of the collaborators, under RHIO monitor. I am also the coordinator of our regional RHIO.

I understand that executives at other hospitals are concerned that publicizing their "central line infection" rates would lead to making unfair comparisons among hospitals, since they collect their data in different ways. You think publication would permit patients to see if individual hospitals are improving on their own rates.

There is a simple way to overcome the objections and meet yourobjectives: Normalize the numbers. Choose a specific starting month-- the same for all the hospitals -- and have each report their figure as 1.0. For each succeeding month, each hospital divides the number of infections by the number that occurred in the starting month, and reports that figure.

For example: If Beth Israel Deaconess had 5 infections in January and 8 in February, it would report 1.0 for January and 1.6 for February. If Mass. General had 10 in January and 7 in February, it would report 1.0 for January and 0.7 for February.

Paul, two thoughts:1) the copyright thing is real; even the excerpted Globe article is a bit much. People who read blogs can follow a link - you don't need much more.2) I think you ought to say something more systematic about quality - you've written about central line infection, ventilator-assisted pneumonias, hospital standardized mortality ratio and perhaps some other metrics of quality. Which of these metrics - and those you haven't mentioned - are the most important? What would a good report card or dashboard on the quality of hospital care look like? If some physicians and administrators think we need standardized metrics for things like infection rates, what should we use?

I don't expect that you'll have the answers to these questions at your fingertips, but you have a quality department, I'm sure, and access to the many fine clinicians, journals and think tanks who study quality in medicine. It would be great to see a major teaching hospital tell its public "here are the 6 or 10 measures you should look for to measure quality of hospital care, and here's how we compare to the nation / region / key competitors." Perhaps, at a minimum, you could invite these some of these experts to offer their thoughts via your blog.

Hey Paul you're doing the community a great service with this blog. I work in nursing and I can tell you- many have NO clue what a blog even is, so this might explain why there are a certain number of folks who are...resentful of this. Don't let them get you down. Keep on blogging and set the standards a little higher for others. People need information they can USE...not press releases and filtered down reports. I think business executives in many industries could benefit by directly blogging to the world.

Well, she said cynically, they might not be too busy if they would stop shooting all those commercials at B&W. I mean, do you have any idea of how creepy it is to see your cardiologist and your cardiac surgeon on TV shilling their services? And I LIKE them....

Paul, I too found your blog after seeing the Globe article. Keep up the good work. I used to do medical malpractice defense and health care law advisory work before shifting to another area of litigation, but I was constantly depressed by the way the peer review & DPH incident reporting process failed to systematically address cases and incidents my firm would see year in, year out, regardless of the hospital. There are systematic improevements to be made, but none of them will happen without the impetus that the sheer terror of transparency will provide.

The US copyright office (perhaps soon it will be a division of the Department of Homeland Security) published a bit on "fair use" here:http://www.copyright.gov/fls/fl102.html

Generally the way this is interpreted is that if the purpose is to discuss issues important to the public (those that appear in the news would likely qualify) then reproducing the material is acceptable (but not in whole). I run a blog and take pieces of articles where they serve the point.

As the copyright office says, there's no magic amount of text that causes the use of copyrighted material to cross the fair use line. I'd say that the use of material is bound by common sense, the requirement of attribution, and the context in which it is presented.

Have to agree with Karen Nelson. Reporting is not new, although for some reason a few hospitals are making themselves out as heroes for doing it. In the early 1990s, the hospitals in Cleveland engaged in a citywide quality improvement and transparency project with the cooperation of employers. And, as mentioned, some quality information is already accessible online. People just don't know about it, or how to use it. (How many people know what a central line is?)

Second point: Insurers limit the use that consumers can make of hospital quality information. Consumers cannot simply choose one hospital over another. A consumer must find a physician who practices at their preferred hospital and will accept their insurance. The consumer also has to be willing to accept a lower insurance payment if their chosen hospital is "out-of-network." This difference can mean thousands of dollars.

So let's not get irrationally exuberant over transparency; it's good, but it's no panacea.

It may be that one reason consumers do not use currently posted information is that it is woefully out of date, often two years old or worse.

It may also be that, until now, they have not had much choice in where to go for hospital care. But that is changing (at least in Boston). Cancer patients, for example, often shop around before choosing where to have treatment. In MA, all the major insurers permit you to get care at all the major hospitals.

Finally, no one is claiming that disclosure is a panacea for anything, so let's not create that straw man just to shoot it down. There is a significant number of people who would like real time accurate information, though, and I believe that number will be growing.

Finally, the idea of creating standards for reporting before current information is posted just does not ring true. There ARE standard formats for reporting information already, but an important problem is that the posted information is way out of date.

Finally, finally, I hope everyone recognizes that there are nonquantifiable aspects of hospital care than can be equally important. The most obvious is the quality of the nursing care, something difficult to measure but clearly of great significance to patients and their families.

We are blessed in Boston to have several really terrific major hospitals (BIDMC, MGH, Brigham and Women's, NEMC, BMC). I think we would all readily send our familiy members to any one of them.

Nonethless, I can't think of any hospital president who would say he or she are totally satisfied with the level of care in his or her hospital. What I am seeking by engaging in these topics is a way of having us all improve and creating more and more public confidence in us all.

I started this as a comment to the blog, but discovered I couldn't say what I needed to succinctly enough, so it's really ended up as more of a message to you directly than a blog comment. I have no need to see it posted publicly, although you certainly may do so if you like.

I'm fascinated by this IT effort, although there's so much inside jargon in the description of it, I'm not sure what it all means in pratice from the patient's point of view.

Just before you came on board, my frail elderly spectacularly anemic mother was hospitalized at BI for colonoscopy and other tests (with of course the presumption she had colon cancer, which it turned out she did not, thankfully).

Although every single person we encountered at the hospital was indeed warm, caring, friendly, concerned, nevertheless, the utter inability of all these nice people -- threee shifts worth of attending physicians and specialists and residents and interns and nurses and technicians -- to communicate *with each other* created a series of errors that meant this fragile and underweight old lady was there on a clear liquid diet for 11 full days, was discharged in dramatically worse shape than when she was admitted, and had to spend an additional 8 weeks in rehab before she could go home. All for fairly simple diagnosis of the source of a GI bleed!

I'll spare you all the details, but the highlights included the GI department literally forgetting to put her on the schedule for the colonoscopy, and the development of truly frightening symptoms that went undiagnosed for three days, though they are a well-known side effect of a common drug she was given. I, a layman, knew the drug had this effect, but I was not told she had been given it.

So hugely complicating the comedy of errors (except it wasn't so funny) was the inability of most of the medical staff to grasp the fact that communicating medical information and instructions only to an exhausted, hearing- and sight-impaired, confused old lady who spent most of the day dozing made no sense whatsoever, nor did relying only on her to answer questions about her medical history and current symptoms.

My name was on all the forms as her caretaker and authorized confidante on all medical issues, and yet information was given to me only randomly. And in one case, I had a major conflict with a physician who insisted that because my 89-year-old (!) mother had seemed rational when he spoke to her, he had an ethical obligation to communicate matters of serious medical import to her alone.

When we finally got out of your hospital, we vowed never, ever to go back, and I subsequently heard many such horror stories of lack of coordination and communication at BI from friends and neighbors.

My mother's two subsequent hospitalizations at Winchester Hospital and Mt. Auburn had none of these problems. Staff were equally as caring and friendly, but in both cases, all the medical personal involved in my mother's care were up to the minute on the details of her situation, and all automatically included me as a member of the team managing her care.

Huge teaching institutions like BIDMC obviously have a much, much bigger problem achieving that kind of coordination than a relatively small community hospital, and I understand that. But I hope that what I'm reading here -- as I say, can't quite tell through the jargon -- is some indication that you and your team understand the problem and are working hard to fix it.

I remember marveling at the time that my friend the wine and liquor salesman never made a call without his computerized tablet that accessed the entire history of the customer's dealings with his company, and yet I rarely saw the BI folks who came into my mother's room so much as crack her paper medical chart, and of course, they rarely were aware of the more recent developments -- whether symptoms, meds or tests -- in her case, never mind a speck of her medical history.

There seemed to me two problems-- one was the sheer difficulty of having to excavate information from hasty scribbles on a long paper chart.

But second, and more important, was a culture that seemed content to carry on without that information or communication. It just didn't seem to be all that important, and I never saw any evidence of frustation about it.

A third major problem was the utter incoherence of the approach to patient confidentiality issues.

And lastly, boy, you guys in the medical profession have no clue whatsoever how to deal with elderly patients. Almost nobody had a glimmer of an idea how to make themselves understandable to the hearing-impaired, which almost all elderly people are to one degree or another. Almost all seemed oblivious to the extreme feeling of physical vulnerability the frail elderly have, and their terror at being brusquely pushed and prodded and pounced and bounced at. And none at all seemed to grasp the fact that just because an elderly person appears more or less coherent doesn't mean their short-term memory is intact and that they can retain information they're given. And I won't even start on the idiocy of giving full adult dosages of powerful meds to frail underweight 90-year-olds and being surprised when there are side effects. Argh.

I came to your blog, I'm sure like many others, as a result of reading the piece in the Globe. My mother passed away a year-and-a-half ago at 93, but I'm still carrying the frustration of the BI experience around with me. The effects on poor old Mom were not life-threatening, but geez, they sure were thoroughly demoralizing to her. To say nothing of the colossal waste of Medicare's money for the unnecessarily extended hospital stay and the many additional weeks of rehab.

So if this whole complex is something you're keenly aware of and are working hard to fix, bravo to you.

If not, why not?

I wish you all the best (though I still hope I never have to enter your institution again!)

It sounds like an awful experience, and I apologize (even though it happened before I got here.)

Every one of the issues you mentioned has been a target for improvement in our hospital -- and I also know that others around town and in the rest of the country have been working on those, too. As noted in several of my posts, we have made good progress on many of these, but I am not going to gloss over the fact that there is room for improvement.

We look for help and advice wherever we can get it -- from patients and families, from groups like IHI, and from other industries. One reason for posting clinical results is to keep pressure on ourselves.

The article made me laugh twice -- first when the Glynn quipped "what's a blog?" and second when the Partners spokesperson Langer dismissively said that the people there are too busy to be blogging.

Well, if Mr. Glynn really does not know what a blog is, that is quite troubling. There is so much cutting edge information about news in general, not to mention about health and health care, much of it in blog form, that the statement just makes one wonder...

As for being too busy ... I guess if they are busy getting that infection rate down, it is a good kind of busy.

On the fair use thing -- I think you are fine. The Globe probably welcomes the exposure ... maybe you should charge them!

Just an FYI, if you actually see/hear of other hospitals wanting to self-publish comparative infection rates, and you can't get the state to build you a home for it, we'd be happy to do it pro bono. Wouldn't necessarily have to be state-based either, although finding a way to fairly compare would be up to you all.

Either way, we can whip up a database / Web page for anyone wanting to post their rates in a day or two. (In three we can even make it purty...)